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A nurse is receiving information about four children during change-of-shift report. Which of the following children should the nurse assess first?

A.

A 12-year-old child who has cystic fibrosis and reports difficulty clearing secretions

B.

A 3-year-old child who has an atrial septal defect and a heart rate of 120/min

C.

A 5-year-old child who has type 1 diabetes mellitus and a blood sugar of 150 mg/dL

D.

A 2-year-old child who has diarrhea and reports abdominal pain

Answer and Explanation

The Correct Answer is A

A. A child with cystic fibrosis and difficulty clearing secretions is the priority because airway clearance is critical in cystic fibrosis. Mucus buildup can lead to respiratory distress and infection, requiring immediate intervention.
B. A child with an atrial septal defect and a heart rate of 120/min is not the priority because a heart rate of 120/min is within the expected range for a 3-year-old and does not indicate immediate distress.
C. A child with type 1 diabetes and a blood sugar of 150 mg/dL is not the priority because this blood glucose level is slightly elevated but not critical.
D. A child with diarrhea and abdominal pain requires assessment, but dehydration or electrolyte imbalance develops over time. Airway issues take priority over gastrointestinal symptoms.


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Related Questions

Correct Answer is C

Explanation

A. Decaffeinated coffee is not recommended for clients with GERD because it can still increase gastric acid secretion, which may worsen symptoms.
B. Tomato soup is acidic and can trigger acid reflux, making it an unsuitable choice for clients with GERD.
C. White fish is a low-fat, non-acidic protein source that is unlikely to trigger GERD symptoms, making it an appropriate dietary choice.
D. Hot cocoa contains chocolate and caffeine, both of which can relax the lower esophageal sphincter (LES) and increase acid reflux.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

Findings Consistent with Chorioamnionitis:

  • Purulent amniotic fluid
  • Fever

Findings Consistent with Preeclampsia:

  • Elevated uric acid level
  • Decreased platelet count
  • Blurred vision

Rationale:

  • Purulent amniotic fluid (Chorioamnionitis): Chorioamnionitis is an intra-amniotic infection, often leading to foul-smelling, purulent, or discolored amniotic fluid.
  • Fever (Chorioamnionitis): Maternal fever is a hallmark sign of chorioamnionitis, indicating infection.
  • Elevated uric acid level (Preeclampsia): Uric acid elevation is associated with endothelial dysfunction and reduced renal clearance seen in preeclampsia.
  • Decreased platelet count (Preeclampsia): Thrombocytopenia can occur due to platelet consumption in severe preeclampsia or HELLP syndrome.
  • Blurred vision (Preeclampsia): Visual disturbances occur due to cerebral edema and vasospasms, common in preeclampsia.

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